Success Story: Northwell Health/SI CARES

“The patient had been found unresponsive in the streets on Staten Island in Feb 2018 and brought to SIUH. His initial stay was 5 days.

The patient is a 53 year old Hispanic male that was referred to Health Homes at Risk by ED Social Worker for assistance in finding a PCP.

I called the contact telephone number several times (3) and finally in mid-March 2018, I decided to send him a letter to see if he responds. After about 1 month, I was going to close him when he called.

Trust is a big part of the work that we do. In February he was inpatient at SIUH for 5 days. We spoke on the phone and he confessed that he doesn’t know what happened to him when he when he blacked out and was initially hospitalized. I didn’t get a sense of him doing drugs or ETOH. He admitted that he was homeless but wouldn’t elaborate much. I do know that he was scared. He admitted that he needed help because he was new to NY and didn’t know where to go to get services.

I could have made him an appt with one of the doctors of the SIUH MAP clinic but I didn’t think that was the right place for him. I always try to pick a (PCP) provider that the patient might relate to, so I decided to make him an appt at SIUH South with Dr. Tirado. He has a history of getting the most complex patients with a history of substance use. I told him that it was very important that he keep this appt for one main reason: He needed to establish his medical condition so that he can apply for benefits. In applying for benefits this is crucial.

Dr. Tirado immediately referred him to a Dr. Perell (neurologist) who saw him the next day. It turns out the patient was taking the wrong medication for the seizures. He was taking the DM medication thinking it was for the seizure.

In late April, the patient called me sounding very depressed saying that he had been staying with a niece and her spouse. It seems that the spouse had been drinking and started hitting his niece. There had been a history of domestic violence. He didn’t get involved but admitted that he couldn’t live under such a stressful situation and stated that he wanted to go to a shelter. I provided him with travel direction and what to expect when went to Project Hospitality (housing program) and that there were no shelters on SI. That he would need to go to the NYC HRA Men’s shelter on 30th street. And I explained to him what to expect. He said he would go.

A day later, I received a call from a doctor in RUMC ED that they had the patient there. He had another seizure in the street and was taken there. I was able to provide the contact information for the neurologist that he had seen. He was inpatient at RUMC for 5 days. Many patients travel back and forth between both hospitals with duplication of many expensive tests. After the discharge he returned to his niece’s house where he currently resides. Her spouse is no longer in the home. The patient told me that he would like to return back to Colorado where he lived once. I believe that there’s someone there that he has history with.

In mid-June 2018, I finally had the opportunity to meet him face to face. He came to my office, I showed him how to apply for housing through NYC HPD Housing Connect Lottery and I provided him with an application for a cell phone from Assurance wireless. It has been a long journey for David. He is very proud of who he is but was willing to let me help him find his way.

These are the services that I helped him with: PCP, Neurology, Public Assistance, Transportation, Dentist, Housing and Assurance Wireless telephone.”